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ROW PERMIT NO.. ENG
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ISSUE DATE-
RIGHT-OF-WAYCONS"I"I RIX"rION
PERMITAPPLICATION'
PROJECT NAME,:
CONTRACTOR:
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Mailing Address:
State License
City Business icense th
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CONTACT:
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Phone#:
Fax #:
Emailik
L'i"Ibility Insurance m gonded
ADDRESS OR INTERSECTION OFCONSTRUCTION.
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ROW WORK ASSAT ED WITH THE FOLLOWING TYPE OF PROJECT:
El Commercial ',LP Subdivision El City Project Traffic Control (Only)
El Multi -Family El Single Family [�] Other
n EUC (PUD, VERIZON, PSE,
CONICAST, OVWSD):
Is this permit part of a blal*et permit?
LANY ASSOCIATED PERMITS?
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BLD# LNG#
DESCRIPTION OF PROPOSED WORK (Be Specific): �0v
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I WAS STREET OVERT.., .YE WITHIN THE LAST FIVE (5) YEARS? YES [] NOS Year:_____�
PAVE MENT C UT: [7 es ❑No If yes, intisize of cut" x
Y
CONCRE'"I'E CUT: r I Yes E] No If yes, indicate size of cut: x
APPLICANT TO READ AND SIGN
*Traffic control and public safety shall be in accordance with City regulations as required by the City
Engineer. Every flagger must be trained as required by (WAC) 296-155-305 and must have certification
verifying completion of the required training in their possession.
*Restoration is to be in accordance with City codes and Standards. All street -cut trench work shall be
patched with asphalt or City approved material prior to the end of the workday — NO EXCEPTIONS.
! If W'1); The Applicant has signed an application which states helshe hold the City of
Edmonds harmless from injuries, damages or clahns of any kind or description
whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or
-3ny of its departments or employees, including defense costs and attomey he by reas
*f granting this permit.
I have read the above statements and understand the permit requirements and acknowledge that I must
-follow all requirements ' r
orde" or the permit to be valid.
order'
SIGNATURE DATE
n," actor or Agent
NO,' f I . SHALL BEGM PRIOR']", 0 PEMMIT' ISSIJANCE